Provider Demographics
NPI:1124795836
Name:COUNTY LINE HEALTH CLINIC
Entity type:Organization
Organization Name:COUNTY LINE HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHELBY
Authorized Official - Middle Name:
Authorized Official - Last Name:CASPER
Authorized Official - Suffix:
Authorized Official - Credentials:MSN-FNP
Authorized Official - Phone:719-688-9962
Mailing Address - Street 1:36053 US HIGHWAY 287
Mailing Address - Street 2:
Mailing Address - City:WILEY
Mailing Address - State:CO
Mailing Address - Zip Code:81092-9702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36053 US HIGHWAY 287
Practice Address - Street 2:
Practice Address - City:WILEY
Practice Address - State:CO
Practice Address - Zip Code:81092-9702
Practice Address - Country:US
Practice Address - Phone:719-688-9962
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-30
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty